Expanding Indications of Transcatheter Heart Valve Interventions

Abstract

Transcatheter aortic valve replacement (TAVR) has been established as a less invasive alternative to open-heart surgery in inoperable or high-risk patients presenting with symptomatic severe aortic valve stenosis. The feasibility and efficacy of valve-in-valve implantation in degenerated surgical aortic bioprostheses have also been described and can currently be considered a valuable treatment option in patients deemed unsuitable for repeat cardiac surgery. However, the clinical use of TAVR devices is not limited to the treatment of the tricuspid stenotic aortic valve. Several additional indications including treatment of the bicuspid stenotic aortic valve, aortic regurgitation, and valve-in-valve or valve-in-ring implantation in the mitral or tricuspid position as well as treatment of pure mitral, tricuspid, or pulmonary regurgitation have been described. The purpose of the present review is to summarize the available evidence concerning the emerging off-label use of TAVR devices in current clinical practice. Case examples have been selected to highlight the main procedural steps of each particular intervention.

Transcatheter Mitral Valve Replacement with the Edwards Sapien 3 Valve

“…However, the transcatheter MV experience remains restricted to the MitraClip ® NT (Abbott Laboratories; Abbott Park, Ill) in selected cases of mitral regurgitation, and to the limited off-label implantation of the Sapien 3 valve for valve-in-valve procedures or in the presence of severe mitral annular calcification. 3,6 The development of percutaneous valves specifically for the mitral position is still in the early clinical stage. 5 The Sapien 3 was designed to be deployed in a rigid structure, such as a calcified aortic annulus (for TAVR), and use has been extended to implantation into a predeployed Palmaz stent in the pulmonary position or into a degenerated bioprosthetic valve for valve-in-valve procedures in any position.…”

“…1,2 Valve-in-valve therapies performed in the tricuspid, pulmonic, mitral, and aortic positions have also been reported, with varying results. 3,4 In regard to the mitral valve (MV), favorable outcomes in patients after mitral valve-in-valve replacement are being reported more frequently, 5 and reports are emerging of mitral valve-in-ring replacement 3 and MVR in patients with severe annular calcification. 6,7 There are no reported cases of commercially available devices having been used for transcatheter valve replacement of a native MV.…”

“…6,7 There are no reported cases of commercially available devices having been used for transcatheter valve replacement of a native MV. 3 In this report, we describe the case of a patient with severe MV stenosis and regurgitation, but without significant annular calcification, who underwent transcatheter MVR replacement with use of the Edwards Sapien 3 valve.…”

Who is the next for aortic valve implantation? Present and future indications

“…TAVI for pure native AR has been shown to be more difficult and associated with lower procedural success, safety, and clinical efficacy rates [41] . Possible explanations for this limited success are related to the concept that a certain amount of aortic annulus and/ore valve calcification is necessary to anchor a balloon-or self-expandable transcatheter valve prosthesis into the annulus [2] .…”

Transcatheter aortic valve implantation. Expert Consensus of the Association of Cardiovascular Interventions of the Polish Cardiac Society and the Polish Society of Cardio-Thoracic Surgeons, approved by the Board of the Polish Cardiac Society…

“…Such procedures may be performed transapically or transseptally, depending on patient anatomy, the TAVI prosthesis used and operators'experience. Careful pre-procedural planning with data on previous mitral operation, TEE and MSCT analysis are crucial to assess ViV feasibility, to select the optimal type and size of TAVI bioprosthesis and to agree on its intraprocedural positioning and the degree of over-expansion [43].…”